No / Effective record keeping underpins service delivery and provides a record of the quality of care delivered. Pressure ulcer risk assessment, prevention strategy and pressure ulcer care provision are a key element in the nursing process and are correctly a focus area within the safety agenda. This article reviews issues related to the documentation of pressure ulcer risk assessment and prevention and asks whether the time is right to move towards a universal system of pressure ulcer care documentation, linked to reporting within the NHS.

Previous literature showed weak and sometimes contradictory evidence regarding the best interventions to prevent pressure ulcers and the best factors that can serve as predictors for ulceration. The aim of this study was to explore effective interventions and associated risk factors in the area of pressure ulcer. A retrospective approach was used to explore such interventions and risk factors in a more natural clinical environment than found in a prospective study. While retrospective studies have their limitations, one problem of prospective studies, the Hawthorn effect, is not present. In order to meet the aims of the study, a matched case-controlled design was employed. A convenience sampling technique was used to select all patients who matched the study criteria. Two groups of patients were selected. The first group developed pressure ulcer during hospitalization, the other did not. In order to have a sound and robust comparison, each patient from the pressure ulcer groups was matched or at least nearly matched with another patient from the non-pressure ulcer group for a number Waterlow sub-scores. Further criteria for selection included a minimum of three days total length of stay in hospital and being initially free of any pressure ulcer on admission for both of the study groups. Electronic medical records for all patients were revised, and multidimensional data were extracted using a data extraction sheet. Data analyses were carried out using univariate analysis (t-test, Mann-Whitney, Chi-square and Fisher’s exact test) and multivariate analysis (binary logistic regression). In univariate analysis for preventive interventions, the following interventions were significantly associated with pressure ulcer prevention (P≤ 0.05): standard hospital bed, seating cushion, static pressure redistributing mattress, re-positioning every four hours and helping the patient to sit regularly in a chair. When the effect of all interventions was adjusted through the multivariate model, the following interventions were independently associated with prevention: draw sheet, re-positioning every four hours and helping patient to sit regularly in chair (odds ratio = 0.24, 0.06 and 0.13 respectively; P≤ 0.05). In univariate analysis for risk factors related to physical activity and mobility, the following factors were significantly associated with developing pressure ulcer (P≤ 0.05): moving in bed with help, the ability to take a bath only in bed, needing two helpers in performing activities of daily living and moving outside bed only by a hoist. When adjusting the effect of all variables related to physical activity and mobility through the multivariate model, only two factors were independently associated with developing pressure ulcer: moving in bed with help and the ability to take a bath only in bed (odds ratio = 7.69 and 3.67 respectively; P≤ 0.05). In univariate analysis for risk factors related to pressure ulcer intrinsic risk factors, the following factors were significantly associated with developing pressure ulcer (P≤ 0.05): presence of three underlying medical conditions, dehydration, depression, having a blood transfusion, serum albumin <32mg/dl, haemoglobin <130 g/l in males or <115 for females and systolic blood pressure <113 mmHg. When adjusting the effect of all variables related to intrinsic risk factors through the multivariate model, the following risk factors were independently associated with pressure ulcer: presence of two underlying medical conditions, presence of three underlying medical conditions, cognitive impairment, serum albumin <32mg/dl and haemoglobin <130 g/l in males or <115 for females (odds ratio = 13.3, 143, 4.3, 0.10 and 0.14 respectively; P≤ 0.05). Findings from this study suggest a number of interventions to be effective in PUs prevention, and a number of risk factors that can predict risk of PUs. Findings were based on statistical association between acquiring PUs and the independent variables (preventive interventions and risk factors). This cannot constitute a cause and effect relationship due to the retrospective nature of data analyzed; it only supports the association between a number of interventions and risk factors in preventing or predicting PUs. This can guide further research to investigate these interventions and risk factors by employing the same approach used, but in a prospective manner.

Aims and Objectives: To compare three risk assessment scales with respect to predictive validity Background: In paediatrics there are several competing scales and at least ten published paediatric pressure ulcer risk assessment scales have been identified. However there are few studies exploring the validity of such scales, and none identified that compares paediatric risk assessment scales. Design: Cross sectional study Methods: Three risk assessment scales, Braden Q, Garvin and Glamorgan, were compared. The total scores and sub-scores were tested to determine if children with pressure ulcers were significantly different from those with no pressure ulcer. Logistic regression was conducted to determine if the probability of developing a pressure ulcer was a better predictor of development of pressure ulcer compared with the total score of each scale. Receiver operating characteristic curves were computed and the area under the curve used to compare the performance of the risk assessment scales. Results: Data from 236 children were collected. 71 were from children in eleven hospitals who were asked to provide data on children with pressure ulcers (although seventeen did not have a pressure ulcer) of whom five were deep (grade 4). A sample of 165 were from one hospital, of which seven had a pressure ulcer, none grade four. The Glamorgan risk assessment scale had a higher predictive ability than either the Braden Q or Garvin. The mobility sub-score of each of the risk assessment scales was the most predictive in each case. Conclusions: The Glamorgan scale is the most valid of the three paediatric risk assessment scales studied in this population. Mobility alone may be as effective as employing the more complex risk assessment scale. Relevance to clinical practice: If a paediatric risk assessment scale is employed to predict risk, then unless it is valid, it may identify children who are not at risk and waste resources, or fail to identify children at risk possibly resulting in adverse health outcomes.

Pressure ulcers (PUs) present intrinsic risk factors that are not consistently identified by clinical assessments. The objective of this project was to develop a clinical practice guideline (CPG) to provide nurses with guidance in identifying and differentiating how intrinsic and extrinsic risk factors are associated with populations at risk for developing avoidable and unavoidable PUs. CPG development followed a systematic method to search the literature, organize findings, and assess the strength of the resulting evidence and its applicability to the CPG. Quality of the CPG was assessed by a panel of 8 health care professionals using the Appraisal of Guidelines for Research & Evaluation II instrument. Findings of the assessment indicated a high overall quality of the CPG; its immediate use was recommended and systematic evaluation was suggested to promote usage in a wider array of health care contexts. The quality domains with the highest scores were scope, purpose, applicability, editorial independence (all 100%), rigor of development (99.7%), and clarity of presentation (99.3%). The stakeholder involvement domain demonstrated the lowest--yet still robust--score (94.4%). The CPG can be used to emphasize appropriate and specific nursing competencies for making informed decisions when identifying and describing patients at risk for developing PUs. Further research and evaluation of the use of this CPG will be useful to demonstrate how CPGs can help to decrease the incidence of avoidable PUs. The potential for positive social change relative to the prevention of PUs is high. Decreased incidence of preventable PUs will eliminate unnecessary health care costs and improve overall health outcomes of patients at all levels of socioeconomic status.

No / Many service commissioners are demanding a reduction in pressure ulcer prevalence and regard pressure ulceration as a key indicator of care quality. Within our area of practice, local commissioners have indicated that all health care providers in the district should work together to reduce pressure ulceration across the local health care economy. Health care professionals clearly have a critical role to play in patient assessment, risk categorisation, care planning and equipment provision. However, this alone will not be sufficient to achieve the reduction targets which will involve effective patient engagement. National and International guidelines all recognise the importance of patient education in care and recognise the significance of patient involvement in personalised care planning and service provision. Hartigan et al have demonstrated the value of education leaflets in supporting pressure ulcer prevention in an elderly population. Patient support applications running on mobile phones and tablets are also available to assist in pressure ulcer prevention and patient education but are not widely used in a hospital setting. This study examines how effective standard verbal and written information is at delivering patient education for pressure ulcer prevention. Local hospital policy is that all patients identied as being at risk of developing pressure ulceration are provided with information on what a pressure ulcer is, what constitutes risk and how to assist staff in pressure ulcer prevention. The policy includes patient and carer involvement in care planning, and encouragement to report skin changes and pain to staff.

No description available.

Thesis advisor: Barbara E. Wolfe / Patient quality outcomes in the United States (U.S.) healthcare system are largely stagnant or making minimal improvements, resulting in unnecessary morbidity, mortality, and costs (AHRQ, 2012 National Healthcare Quality Report). As the US implements the 2010 Patient Protection and Affordability Act, there is fiscal pressure to attain and sustain significant improvements to patient quality outcomes. This necessitates an understanding of how the processes and structures of care influence patient quality outcomes (Donabedian, 1966) in a complex care environment. To begin addressing this gap, this investigation examined the influence of unit-level authentic leadership (AL) and structural empowerment (SE) on staff nurse decisional involvement (DI) and patient quality outcomes on general care units in the acute-care hospital setting. This study used a cross-sectional survey design. Participants were staff nurses working on 105 general care units across eleven US hospitals. The surveys measured staff nurse perceptions of AL, SE, and DI at the care unit level. The patient quality outcomes of interest were falls with injury, hospital acquired pressure ulcers and patient satisfaction. Care unit level AL and SE had a significant influence on actual staff nurse DI (p = .002 and < .001, respectively) and the degree of dissonance between actual and preferred DI (p < .001). AL and SE had a significant inverse relationship with patient falls with injury (p = .017 and .028, respectively), yet a positive relationship with HAPU rates (p = .051 and .026, respectively). While AL did not have a significant relationship with any of the three patient satisfaction metrics, a significant positive relationship with SE was found (p = .002, .001, and .002, respectively). There was no support for a relationship between actual staff nurse DI and any of the patient quality outcomes. This study extends previous research in this area in that it is the first to examine actual patient quality outcomes at the care unit level. These findings provide support for the unique contributions to patient quality outcomes at the care unit level, indicating the need to develop AL among front-line nurse managers and SE in nurse work environments. / Thesis (PhD) — Boston College, 2015. / Submitted to: Boston College. Connell School of Nursing. / Discipline: Nursing.

Pressure ulcers (PU) are localized damage to skin and underlying tissue that forms in response to ischemia and subsequent hypoxia from external applied mechanical loads such as pressure. We demonstrate how a multiscale and multiphysics finite element model can capture the process of pressure ulcer formation.

Nutritional interventions as a prevention and treatment of pressure ulcers in geriatric clients living in social services facilities Introduction: Pressure ulcers are chronic wounds caused by pressure and friction. This is localized area of cell damage caused by a microcirculation disorder. Prevention is essential especially for immobile clients who are easily creating and developing these chronic wounds. Clinical practice shows that client positioning, use of anti-decubital aids and good nutritional support is necessary. It is important to increase the supply of individual nutrients, especially proteins, and monitor their sufficiency for treatment and prevention. The theoretical part of this diploma thesis was devoted to the etiopathogenesis, classification, prevention and treatment of pressure ulcers especially in terms of nutrition. The empirical part was focused on the examination of the nutritional status of clients with pressure ulcers (using the Mini Nutritional Assessment-Short Form questionnaire) and the concretization of the nutritional needs and the real balance of the clients with newly established pressure ulcers at the beginning and after three months of nursing. Objectives: The main objective of this thesis was to map, how many of institutionalized clients with pressure ulcers had sufficient...

Malnutrition is reported to be common in hospitals (10-60%), residential aged care facilities (up to 50% or more) and in free living individuals with severe or multiple disease (>10%) (Stratton et al., 2003). Published Australian studies indicate similar results (Beck et al., 2001, Ferguson et al., 1997, Lazarus and Hamlyn, 2005, Middleton et al., 2001, Visvanathan et al., 2003), but are generally limited in number, with none conducted across multiple centres or in residential aged care facilities. In Australia, there is a general lack of awareness and recognition of the problem of malnutrition, with currently no policy, standards or guidelines related to the identification, prevention and treatment of malnutrition. Malnutrition has been found to be associated with the development of pressure ulcers, but studies are limited. The consequences of the development of pressure ulcers include pain and discomfort for the patient, and considerable costs associated with treatment and increased length of stay. Pressure ulcers are considered largely preventable, and the demand for the establishment of appropriate policy, standards and guidelines regarding pressure ulcers has recently become important because the incidence and prevalence of pressure ulcers is increasingly being considered a parameter of quality of care. The aims of this study program were to firstly determine the prevalence of malnutrition and its association with pressure ulcers in Queensland Health hospitals and residential aged care facilities; and secondly to estimate the potential economic consequences of malnutrition by determining the costs arising from pressure ulcer attributable to malnutrition; and the economic outcomes of an intervention to address malnutrition in the prevention of pressure ulcers. The study program was conducted in two phases: an epidemiological study phase and an economic modelling study phase. In phase one, a multi centre, cross sectional audit of a convenience sample of subjects was carried out as part of a larger audit of pressure ulcers in Queensland public acute and residential aged care facilities in 2002 and again in 2003. Dietitians in 20 hospitals and six aged care facilities conducted single day nutritional status audits of 2208 acute and 839 aged care subjects using the Subjective Global Assessment, in either or both audits. Subjects excluded were obstetric, same day, paediatric and mental health patients. Weighted average proportions of nutritional status categories for acute and residential aged care facilities across the two audits were determined and compared. The effects of gender, age, facility location and medical specialty on malnutrition were determined via logistic regression. The effect of nutritional status on the presence of pressure ulcer was also determined via logistic regression. Logistic regression analyses were carried out using an analysis of correlated data approach with SUDAAN statistical package (Research Triangle Institute, USA) to account for the potential clustering effect of different facilities in the model. In phase two, an exploratory economic modelling framework was used to estimate the number of cases of pressure ulcer, total bed days lost to pressure ulcer and the economic cost of these lost bed days which could be attributed to malnutrition in Queensland public hospitals in 2002/2003. Data was obtained on the number of relevant separations, the incidence rate of pressure ulcer, the independent effect of pressure ulcers on length of stay, the cost of a bed day, and the attributable fraction of malnutrition in the development of pressure ulcers determined using the prevalence of malnutrition, the incidence rate of developing a pressure ulcer and the odds risk of developing a pressure ulcer when malnourished (as determined previously). A probabilistic sensitivity analysis approach was undertaken whereby probability distributions to the specified ranges for the key input parameters were assigned and 1000 Monte Carlo samples made from the input parameters. In an extension of the above model, an economic modelling framework was also used to predict the number of cases of pressure ulcer avoided, number of bed days not lost to pressure ulcer and economic costs if an intensive nutrition support intervention was provided to all nutritionally at risk patients in Queensland public hospitals in 2002/2003 compared to standard care. In addition to the above input parameters, data was obtained on the change in risk in developing a pressure ulcer associated with an intensive nutrition support intervention compared to standard care. The annual monetary cost of the provision of an intensive nutrition support intervention to at risk patients was modelled at a cost of AU$ 3.8-$5.4 million for additional food and nutritional supplements and staffing resources to assist patients with nutritional intake. A probabilistic sensitivity analysis approach was again taken. A mean of 34.7 + 4.0% and 31.4 + 9.5% of acute subjects and a median of 50.0% and 49.2% of residents of aged care facilities were found to be malnourished in Audits 1 and 2, respectively. Variables found to be significantly associated with an increased odds risk of malnutrition included: older age groups, metropolitan location of facility and medical specialty, in particular oncology and critical care. Malnutrition was found to be significantly associated with an increased odds risk of having a pressure ulcer, with the odds risk increasing with severity of malnutrition. In acute facilities moderate malnutrition had an odds risk of 2.2 (95% CI 1.6-3.0, p<0.001) and severe malnutrition had an odds risk of 4.8 (95% CI 3.2-7.2, p<0.001) of having a pressure ulcer. The overall adjusted odds risk of having a pressure ulcer when malnourished (total malnutrition) in an acute facility was 2.6 (95% CI 1.8-3.5, p<0.001). In residential facilities, where the audit results were presented separately, the same pattern applied with moderate malnutrition having an odds risk of 1.7 (95% CI 1.2-2.2, p<0.001) and 2.0 (95% CI 1.5-2.8, p<0.001); and severe malnutrition having an odds risk of 2.8 (95% CI1.2-6.6, p=0.02) and 2.2 (95% CI 1.5-3.1, p<0.001), for Audits 1 and 2 respectively. There was no statistical difference between these odds risk ratios between the audits. The overall adjusted odds risk of having a pressure ulcer when malnourished (total malnutrition) in a residential aged care facility was 1.9 (95% CI 1.3-2.7, p<0.001) and 2.0 (95% CI 1.5-2.7, p<0.001) for Audits 1 and 2 respectively. Being malnourished was also found to be significantly associated with an increased odds risk of having a higher stage and higher number of pressure ulcers, with the odds risk increasing with severity of malnutrition. The economic model predicted a mean of 3666 (Standard deviation 555) cases of pressure ulcer attributable to malnutrition out of a total mean of 11162 (Standard deviation 1210), or approximately 33%, in Queensland public acute hospitals in 2002/2003. The mean number of bed days lost to pressure ulcer that were attributable to malnutrition was predicted to be 16050, which represents approximately 0.67% of total patient bed days in Queensland public hospitals in 2002/2003. The corresponding mean economic costs of pressure ulcer attributable to malnutrition in Queensland public acute hospitals in 2002/2003 were estimated to be almost AU$13 million, out of a total mean estimated cost of pressure ulcer of AU$ 38 526 601. In the extension of the economic model, the mean economic cost of the implementation of an intensive nutrition support intervention was predicted to be a negative value ( -AU$ 5.4 million) with a standard deviation of $AU3.9 million, and interquartile range of –AU$ 7.7 million to –AU$ 2.5 million. Overall there were 951 of the 1000 re-samples where the economic cost is a negative value. This means there was a 95% chance that implementing an intensive nutrition support intervention was overall cost saving, due to reducing the cases of pressure ulcer and hospital bed days lost to pressure ulcer. This research program has demonstrated an independent association between malnutrition and pressure ulcers, on a background of a high prevalence of malnutrition, providing evidence to justify the elevation of malnutrition to a safety and quality issue for Australian healthcare organisations, similarly to pressure ulcers. In addition this research provides preliminary economic evidence to justify the requirement for consideration of healthcare policy, standards and guidelines regarding systems to identify, prevent and treat malnutrition, at least in the case of pressure ulcers in Australia.